At the Medical University of South Carolina (MUSC) in Charleston, a familiar scene plays out in the hospitalist program. New hospitalists express an interest in a certain area and the university tries to accommodate them, making time for them to pursue additional training as they juggle the daily demands of treating patients, says Patrick Cawley, MD, MBA, SFHM, associate professor at the university and a former SHM president.
"We try to have a personal growth plan for each hospitalist that aligns with their interest," Dr. Cawley says. "So if we have a hospitalist that’s very, very interested in quality improvement, we’ll seek out opportunities to get that hospitalist experience, and start with smaller projects and then bigger projects."
As the field of HM hits a notable mark in its history—it’s been 15 years since the term "hospitalist" was coined—more advanced training will continue to emerge as a key issue and obstacle in the field, say experts who were asked to take a look into HM’s crystal ball.
They also predict continued growth of the field, with tens of thousands of new hospitalists emerging in the next decade or so. They also say that hospitalists will emerge as leaders in the application and use of new technology, and that there will be more demands placed on hospitalists to show their worth in hard data.
There also promises to be a growing presence of private management firms providing hospitalists to hospitals, which doctors both inside and outside of those firms say could have a beneficial effect on the overall quality of patient care.
-Patrick Cawley, MD, MBA, SFHM, associate professor, Medical University of South Carolina, Charleston, former SHM president
For now, Dr. Cawley says, at MUSC and elsewhere, hospitalist programs are scrambling for time to enhance the skills needed to tend to increased demands.
"You have to carve out time. That’s literally what you have to do," he explains. "That’s expensive to take a doctor away from clinical service for a week, or an even an hour or two a week. I mean, somebody’s got to pay for that."
Training on hospitalist-specific management topics, he says, needs to evolve further. "I think there’s a recognition that this stuff is important and that hospitals and hospitalists need to get better aligned," he says. "This is something that will continue to mature over the next 10 years."
The range of tasks is growing ever broader for the hospitalist, and so the need for enhanced training is greater, says Larry Wellikson, MD, SFHM, CEO of SHM.
"They’re being asked to do bedside patient care, but they’re being asked to do more. They’re asked to be systems engineers, they’re asked to be safety experts, they’re asked to be the information manager, if you will, the IT guys," he says. "These skills they have not been trained to do and they need … either to say, ‘No, I can’t do that because I haven’t been trained,’ or they need to go and look where they can get that expertise.
"That’s what we try to do at SHM, with our Leadership Academy and our Practice Management Academy."
Frank Michota, MD, FHM, director of academic affairs in the Department of Hospital Medicine at The Cleveland Clinic, says that one of the biggest challenges the field needs to tackle over the next several years is to better standardize the education of hospitalists, saying there is "incredible inconsistency from hospitalist to hospitalist in terms of knowledge base, experience and … understanding the scope of practice."
"We continue to have significant variation in hospital practice models and the types of measurements that are available to those hospitalists for practice improvement," he says. "We continue to see significant turnover in the field with kind of a lack of maturity"—and not the kind of experience base that "you would like to see 15 years in."
"There is really no confidence that everyone at the base of that iceberg will ever make it to the tip because it’s still not viewed by many who entered the field as being a long-term career choice," Dr. Michota says. For many, he said, it is "a look-and-see proposition."
All of this, he says, points to the need for a full certification process by an HM board.
"I don’t want to make it sound like it has not been an impressive evolution to this point, but I think if we are going to meet the expectations, we do have to do more than we’re doing now," Dr. Michota says.
Some of the gaps in training might be able to be filled by private hospital management groups, which have training programs for their doctors that are made possible by their scale and whose presence is predicted to grow over the next 15 years.
Robert Bessler, MD, who in 2001 founded Tacoma, Wash.-based Sound Physicians, which has become one of the largest private hospitalist organizations in the country, says private companies are able to conduct training that is impossible for many hospitals to conduct themselves.
"You’re going to get good people who are all of good training and good knowledge, but they’re not all going to have experience," he says, "and so what are the hospitals that are employing 50% of the hospitalists in this country going to do about that? It’s pretty much nothing. They’re going to occasionally send some people to conferences and hope—because they don’t have that infrastructure."
At teaching institutes like those at private firms, the process is sped up, Dr. Bessler adds.
"That’s why we built our hospitalists’ institute at Sound—to turn really good, quality doctors into effective hospitalists in a much more rapid fashion," he says. "Because before we built this, it was just get them involved and hope after a couple of years they’ve really become efficient. Our hospital partners and the patients can’t wait that long."
Robert Reynolds, MD, founder of PrimeDoc, an Asheville, N.C.-based company that provides doctors for 12 hospitalist programs and employs about 100 doctors, says there needs to be more focus on teaching the "realistic side of the business of medicine," as well as on quality outcomes and patient satisfaction. But he also doubts there will be much change in training.
"[From] my cynical side and the voice of experience, I don’t see any change in the near future," he says. "What we’re seeing now is physicians come out of residency with a good clinical base, but really having no idea of how the healthcare system works in a bigger picture, how it works as an industry. So we’re having to spend a lot of time and effort training physicians to start thinking like practicing physicians."
The experts all agree that there will be an increase in hospitalists being provided by private corporations. Dr. Reynolds says that trend will continue in part due to healthcare reform’s emphasis on outcomes for reimbursement and a corporation’s ability to assist with physician training, as well as data and reporting needs.
"More and more hospital compensation and physician compensation is going to be based on actual data, performance data," he says. "And in order to really do a good job of capturing and reporting that kind of data, you need enough size to support an IT system and training systems that will produce and capture the kind of data that will be necessary."
Erin Fisher, MD, MHM, a pediatric hospitalist at Rady Children’s Hospital in San Diego, says a major goal of the future should be to change the reimbursement structure "so that you have something that is reasonable and encourages appropriate testing, treatments, and coordination of our healthcare system in a systematic way, rather than pieces." In such a system, hospitalists might see something to prompt them to intervene in a preventive way.
"The bigger question is, can our healthcare system, in five to 10 years, change itself enough that it uses every episode of care as an opportunity to do preventive care and coordinate care in the best way?" says Dr. Fisher, an SHM board member.
There is agreement that the field will continue to expand, with SHM predicting that the number of hospitalists in the U.S. will reach 40,000 in the next several years, up from today’s 30,000 figure.
Dr. Wellikson says that the figure could rise to as many as 70,000 or more if specialty hospitalists—such as surgical hospitalists, neuro-hospitalists, and laborists—are included. Those hospital-based specialties are now only in their infancy.
"Everything you can see shows that people are still flocking into hospital medicine," Dr. Wellikson adds.
Hospitalists numbered in the hundreds just 15 years ago, so growth has been explosive the past decade. Dr. Cawley, however, says the pace of growth might be starting to slow already, shifting to undeveloped or underserved areas. "Hospitalist programs are at almost all the large [hospitals] and really the growth has been at the smaller hospitals in the last several years," he says.
With the projected rise of Medicare beneficiaries due to the aging of the baby-boom generation, use of hospitals is expected to skyrocket, meaning more hospitalists will be needed, Dr. Bessler says. He also cites data from the National Rural Health Association noting that 25% of the U.S. population lives in areas considered rural, but that only 10% of the physicians live in those areas, indicating a potential growth area for hospitalists.
"That would tell me that demand will continue to outpace supply," he says.
Mike Tarwater, a member of the board of the American Hospital Association and CEO of Carolinas Medical Center in Charlotte, N.C., agrees with Dr. Bessler. Even with the move toward more outpatient care, Tarwater says, the aging of the population will mean a higher demand for hospitalists.
-Mike Tarwater, board member, American Hospital Association, CEO, Carolinas Medical Center, Charlotte, N.C.
"I think that the primary-care physicians—either because of their love for it or their belief that it’s the better way to go with the treatment of their patients—are going to be really stretched to keep that ambulatory practice going and to get to round on patients in the hospitals," he says. "I think there’s going to be a continued growth of the trend that we’ve seen over the last 15 years."
That growth also will mean a greater emphasis on technology use, whether it’s technology used for quick diagnostics like portable ultrasound or more widely used and refined electronic health records (EHR)—or, as Tarwater describes, "probably things we don’t imagine today."
"Our doctors, more than any other doctors, are tech-savvy; they’re early adopters," Dr. Wellikson says.
Hospitalists likely will emerge as leaders in the adoption of new technology, several experts predict.
Without a doubt, I think that hospitalists are going to be a driving force in the adaptation of the electronic [health] record to the clinical care within their hospitals," Dr. Michota says.
As the needs of HM grow, and the field grows more complex, there will inevitably be more divisions and departments of hospital medicine in places where it is now only a section, Dr. Cawley says.
"When you’re a division or a department, you have more autonomy over your own future, so I see this happening," he says. "I think more and more will carve themselves out of general internal medicine, and a lot of that will come because of a demand for more independence and greater autonomy." TH
Thomas R. Collins is a medical writer based in Florida.